Domestic Violence and the Invisible Injuries

by Dr. Sana Khan

Because of inadequate screening and identification, brain injuries and brain damage in survivors of domestic violence too often remain unrecognized and untreated. Victims of domestic violence who suffer the lasting effects of traumatic brain damage rarely have the support, finances, and other resources to obtain the assistance and funding they so desperately need.

One in four women in the United States, according to the Centers for Disease Control and Injury Prevention (CDC), are estimated to be survivors of domestic violence. One recent study in Arizona estimated that 20 million women each year could be victims of a domestic-related traumatic brain injury (TBI).

A study conducted by the New York State Office for the Prevention of Domestic Violence, examining women in three domestic violence shelters, demonstrated the prevalence of TBIs among domestic violence survivors. According to the study:

• 92% of the women questioned had been hit in the head by their partners more than once.
• 83% were hit in the head and shaken severely.
• 8% were hit in the head over twenty times in the preceding year.

Brain injuries caused by domestic violence include:

• Closed head injury, which occurs when the victim is punched, shaken, pushed, or shoved. It can also occur when an object strikes someone’s head, or when a head is slammed onto a surface;
• Open head injury, which is when the skull is fractured;
• Strangulation leading to deprivation of oxygen to the brain (hypoxia) can occur during deviant sex games or when someone’s head is pushed into the bed, causing breathing difficulty. The brain utilizes as much as 25% of the oxygen we inhale. It is the brain’s fuel. Oxygen deprivation causes the death of brain cells and brain damage occurs. The victim need not lose consciousness for the brain damage to result. Strangulation may also cause decreased blood flow to the brain resulting in brain damage.

Domestic violence does not discriminate based upon income, and neither does TBI. A brain injury and domestic violence can affect anyone, anytime, and anyplace.

Brain Trauma: The Invisible Injury

A brain injury is often difficult to detect, because it is an invisible injury. Following a brain injury, an individual may appear to be fine but nonetheless may be suffering a multitude of physical, emotional, and behavioral injuries caused by the brain damage they sustained. There is a misconception that if abuse occurs, there must be physical, observable signs. TBI is often termed the “invisible injury” by professionals because there are no physical signs.

Injury to the brain can be compared to shaking a raw egg, which leaves the shell intact but ruptures the yolk within. The rapid acceleration and deceleration of the brain within the skull causes damage to nerve fibers and brain structures. When the brain slides within the skull, contact with the interior sharp ridges and edges can cause damage to the brain’s soft tissue. These forces cause the brain to move forward, backward, or rotate within the skull cavity and forcefully propel it against interior protrusions, causing bruising, bleeding, and nerve destruction. Most of the bony prominences are in the front and sides of the skull causing injury to the frontal area (frontal lobe) and the side areas (temporal lobe). The frontal and temporal lobes are responsible for cognitive functions such as memory, concentration, and impulse control. This is why many people who sustain traumatic brain injuries have frontal and temporal lobe damage and symptomology.

The Movement of the Brain Within the Skull

Elementary physics principles can explain the movement of the brain within the skull. A body (or brain) in motion stays in motion. When an individual is pushed or shoved, the victim’s head continues to travel forward in the same direction until the brain is stopped by the skull’s interior surface. The victim is thrown forward or backward, causing their brain to move rapidly within the skull cavity itself. Similarly, when a victim of domestic violence is thrown to the ground, the head moves rapidly, moving the brain within the skull, ending in an abrupt stop. In these situations, the brain, floating in cerebral spinal fluid, does not stop moving immediately but continues, striking and scraping against the skull’s interior rough, hard surfaces, causing injury.

The brain may also be injured due to the stretching or tearing of nerve fibers by movement within the skull. The brain is not a homogeneous substance; but comprises many layers of varying densities. These disparities cause portions of the brain to move at different velocities with different forces applied to each region of the brain. One layer of the brain may glide over another. This intracranial movement at different speeds causes individual nerve fibers to be twisted or stretched, causing a “shearing” injury. Trauma to individual nerve fibers causes damage and a disruption in communication between nerve cells. The violent and sudden movement and turning of the head, which frequently takes place when a victim is thrown or shaken, can also cause rotational damage to the nerve fibers.

Coup and Contrecoup Brain Injury

Injury to the brain may occur in more than one location. Most obvious is the site of impact with an object (coup injury), where there is actual contact between the skull and an object. Injury can also result, however, from the rebounding of the brain in the opposite direction, following impact (contrecoup injury). When the brain rebounds, the portion of the brain on the reverse side can strike the skull, causing damage to the opposite the site of initial impact. When a moving object strikes a stationary skull, such as a baseball bat striking a head, the initial coup injury will be more severe. When a moving skull strikes an immobile object, such as when an individual falls to the ground and strikes their head, the rebound injury, or contrecoup injury, will be more severe.

Rotational Brain Injury

Brain movement is sometimes linear (forward and backward), but may also rotate within the skull. The rotational forces cause a shearing of brain tissue and resulting stretching and tearing of brain axons. This disrupts the ability of the neurons to communicate with each other. This injury is called diffuse axonal injury or DAI. Significantly, it is a major cause of brain damage, impaired consciousness, and death.

Traumatic brain injuries often result in memory and multitasking difficulties, and cognitive fatigue. Memory (the ability to recall) is the product of numerous discrete actions along the neural pathway and is complicated. First, information must be received, auditory or visual, then processed, stored, located, and ultimately retrieved for use. A brain-injured individual may have a disruption anywhere along that route. Executive functioning, multi-tasking and decision-making, is the ability to engage in many tasks simultaneously, and is frequently impaired following a traumatic brain injury.

Cognitive fatigue is also a common complaint of many individuals with a traumatic brain injury. Cognitive fatigue is to your brain and functioning like a computer with too many open programs. The computer continues to function, but in a protracted manner.

A Concussion Is a Brain Injury

A concussion is more than a bump on the head. The CDC acknowledges a concussion is a brain injury that can have permanent consequences, stating “Medical providers may describe a concussion as a “mild” brain injury because concussions are usually not life-threatening. Even so, the effects of a concussion can be serious.”

Concussion Symptoms

Every brain injury is unique and can affect victims in very different ways. Individuals frequently have physical, cognitive, emotional or behavioral symptoms following a concussion. This is the “post-concussion syndrome.” Common symptoms include:

Thinking/Remembering:

• Feeling sluggish
• Difficulty concentrating
• Difficulty remembering new information

Physical:

• Headache
• Nausea or vomiting
• Balance problems
• Dizziness
• Fuzzy or blurred vision
• Feeling tired, having no energy
• Sensitivity to noise or light

Emotional/Mood:

• Irritability
• Sadness
• Increased emotional responses
• Nervousness or anxiety

Sleep Disturbances:

• Sleeping more than usual
• Sleeping less than usual
• Trouble falling asleep

The Risks of Repetitive Head Trauma

Domestic abuse survivors are frequently victims of repetitive head trauma. These repetitive injuries pose additional risks. A victim is more susceptible to a second concussion if it occurs before there is a full recovery from an initial concussion and there is a higher risk of permanent injury if a second concussion takes place before full recovery from the initial concussion. Repetitive sub-concussive blows may cause permanent brain damage.

Radiology Studies May Not Demonstrate Injury

Attorneys searching for objective evidence to document brain trauma caused by a whiplash-type event may be frustrated. Traditional radiological studies, such as CTs or MRIs, are not sensitive enough to display microscopic stretching, tearing, and shearing of nerve cells. The medical adage, “Absence of proof is not proof of absence,” is important to remember. Newer imaging techniques, such as diffusion tensor imaging (DTI) may offer assistance in demonstrating brain damage previously undetectable by traditional imaging studies. With the present state of imaging technology, however, attorneys must generally rely on the testimony of neuropsychologists and lay witnesses who can establish the victim’s condition prior to physical abuse. 

Hospital screening for TBI in Domestic Violence Patients is Inadequate

Victims of domestic violence are not routinely screened for TBI even when they present at the hospital with physical injuries. The majority of domestic violence victims receive no diagnosis of TBI, in part because they do not have visible injuries, and because there is a lack of screening.

If a child comes in from the soccer field or football field with physical injuries or complaining of headaches or nausea, they are worked up for a TBI, but not victims of domestic abuse. A study of the accuracy of emergency department diagnoses of traumatic brain injury found emergency room physicians fail to accurately diagnose a mild traumatic brain injury 56% of the time, despite the patient exhibiting symptoms that meet the definition. 

Screening for Brain Injury in Domestic Abuse Victims

All survivors of domestic violence must be screened for various forms of physical abuse that could lead to brain injury. A special screening tool known as “HELPS” aids in determining whether a victim entering a domestic violence shelter should be seen by a qualified medical provider for further evaluation.

HELPS questions:

• Did your partner ever Hit you in the face or head? With what?
• Did your partner ever slam your head or another object, or push you so that you fell and hit your head?
• Did your partner ever shake you?
• Did your partner ever try to strangle or choke you, or do anything else that made it hard for you to breathe?
• Did you ever go to the Emergency room after an incident? Why?
• Did they ask you whether you had been hit on the head or indicate that they suspected a head injury or concussion?
• Was there ever a time when you thought you needed to go to the ER, but didn’t go because you couldn’t afford it or your partner prevented you?
• If you did go to the ER, did you think you got all the treatment you needed?
• Did you ever Lose consciousness or black out as a result of what your partner did to you?
• Have you been having Problems concentrating or remembering things?
• Are you having trouble finishing things you start to do?
• Are people telling you that you don’t seem like yourself, or that your behavior has changed?
• Does your partner say you have changed, and use that as an excuse to abuse you?
• Have you been having difficulty performing your usual activities?
• Are you experiencing mood swings that you don’t understand?
• Has it gotten harder for you to function when you are under stress?
• Have you been Sick or had physical problems? What kind?
• Do you experience any reoccurring headaches or fatigue?
• Have you experienced any changes in your vision, hearing, or sense of smell or taste?
• Do you find yourself dizzy or experience a lack of balance? 

Valuable Information for Working with Victims of Traumatic Brain Injury Caused by Domestic Violence

It is important in working with any brain injury survivor that they be treated with dignity and respect. Understand their injuries and the many ways they can affect and impact your professional relationship. The following are useful strategies to improve communication and develop good rapport with your client.

In General:

• Allow extra time
• Accept client will be late
• Schedule appointments early in day
• Encourage note-taking
• Be respectful and supportive

Difficulties in Attention & Concentration:

• Minimize distractions
• Keep meetings short
• Avoid bright lights
• Talk slowly
• Repeat important information
• Incorporate short breaks

Memory Difficulties:

• Write down information
• Provide a notebook
• Encourage use of a journal
• Give client checklists
• Repeat critical information
• Obtain feedback

Processing Difficulties:

• Focus on one task at a time
• Breakdown messaging into smaller pieces
• Get feedback to ensure understanding

Victims of brain injury feel misunderstood. They may look and sound fine, but they may have devastating brain damage that affects their ability to navigate day-to-day life. Because they are judged by their outward appearance, the seriousness of their condition is often not appreciated by legal and medical professionals. Brain injury victims have lost a part of themselves. They struggle every day with their deficits and losses of who they used to be.

Dr. Sana Khan is an accomplished radiologist, researcher, teacher and entrepreneur. He was the first radiologist in the US with the Stand-Up Weight-Bearing MRI and has contributed significantly to the advancement of this technology. He is a nationally renowned scientist conducting ongoing research with the Departments of Orthopedic Surgery at UCLA, USC, UCSD, and the US Department of Defense. Having developed state-of-the-art MRI techniques, Dr. Khan brings extensive expertise in the medical-legal aspect of imaging musculoskeletal and traumatic brain injuries. www.expertmri.com